For Nelson Mandela, the first elected president of South Africa, the challenge was to build an integrated post-apartheid society. For Thabo Mbeki, Mandela's successor, the new challenge is to quickly curb the spread of the HIV virus that is now engulfing the country.

Thabo Mbeki

The HIV infection rate among adults in South Africa stands at 22 percent, according to the latest estimates. Barring a medical miracle, one out of every five adults will die within the next decade. Such a massive loss of life will destabilize the country in unimaginable ways, threatening the exciting, hard-won social gains made in the young post-apartheid era.

South Africa has one of the fastest growing HIV epidemics in the world. The 22 percent infection rate-based on antenatal clinic surveys in April of 1999-represents a jump of more than half over the 14 percent estimate from late 1997.

Infection levels are even higher in smaller, neighboring countries, but South Africa, with its total population of 43 million, is the first large nation where the disease has spun out of control.

As in the rest of the world, the highest infection rates in South Africa are found among young adults-the 15-24 age group. Because the virus is spread primarily through unprotected sexual contact, those who are most vulnerable to infection are those who are most sexually active-young adults in the prime of their lives.

Most human scourges--the plague, small pox, influenza--strike the young and the elderly hardest. HIV's assault on young adults is what makes the disease so economically damaging and socially disruptive.

The virus is poised to decimate South Africa's working-age population: the fathers and mothers who support families, the agronomists, engineers, and teachers who form the cornerstone of the national development effort. In the predominantly black and largely impoverished province of Kwazulu-Natal, one in three adults is thought to be infected. At the University of Durban-Westville in Kwazulu-Natal, 25 percent of the student body recently tested positive for HIV-a dismal prospect for the nation's best and brightest.

While the economic fallout from this massive loss of young adults is still poorly understood, the epidemic is already beginning to cut into economic activity. Rising worker health insurance costs are shrinking or even eliminating company profit margins, forcing some into the red. In addition, companies are faced with increases in sick leave, decreased productivity, and rising costs for recruiting and retraining replacements.

Countries where labor forces have such high infection levels will find it increasingly difficult to attract foreign investment. What has begun as an unprecedented social tragedy is beginning to translate into an economic disaster. Municipalities throughout South Africa have been hesitant to publicize the extent of their local epidemics or scale up control efforts for fear of deterring outside investment and tourism.

As in other African nations, the epidemic breeds a new, and rapidly growing, demographic group in South Africa: AIDS orphans. 100,000 children were orphaned by AIDS in 1998 alone. The burden of raising these children falls on the extended family, and then society at large.

The epidemic is overwhelming South Africa's health care system, as hospital, clinics, and medical personnel struggle to treat those suffering from AIDS. Already, AIDS patients are occupying 70 percent of the beds in some hospitals.

As the epidemic siphons funds from health care budgets, South Africa's ability to provide basic health care to the general population-including immunizations and the treatment for routine illnesses-is faltering.

A related effect of the epidemic is a precipitous drop in life expectancy. As recently as 1990, life expectancy in South Africa stood at 59 years, among the highest in Africa. But deaths from AIDS are projected to drive life expectancy below 40 years by 2010.

Perhaps the greatest obstacle to a successful HIV containment strategy for South Africa is the taboo that continues to surround HIV/AIDS. The departing president, Nelson Mandela, did not address the issue publicly until late 1998, well after the severity of the epidemic was known.

According to Robert Shell, a professor at Rhodes University who has been tracking the epidemic, people rarely get tested for fear of coming up positive and those who do know their HIV status often keep it a secret from friends and family to prevent being ostracized.

Last year, in an internationally publicized incident, an HIV-positive woman who "came out" in an effort to boost support for those infected was stoned to death by neighbors who viewed her as a stain on the community.

Experience has shown that leadership is crucial for controlling the virus. In two developing nations that have effectively checked the spread of the virus-Uganda and Thailand-the respective heads of state, President Yoweri Museveni and Prime Minister Anand Panyarachun, personally led the national AIDS campaigns, speaking tirelessly about condom use, sex education, and behavioral change.

Breaking the silence from above not only helped to boost awareness and financial support for prevention efforts, but helped to begin de-stigmatizing the virus, allowing religious, military, academic, corporate, and community leaders to openly embrace the challenge.

Mbeki's victory was nothing short of a landslide; he won 70 percent of the vote. He is ideally positioned to scale up South Africa's current control efforts, making HIV awareness and education mandatory in schools, army barracks, and places of work, and mentioning HIV/AIDS every chance he gets.

This all-out effort is required to protect the lives of those people who put him in office and the hard-fought gains since the end of apartheid.